Claims Systems Specialist- Health Benefits TPA

Job Title: Claims Systems Specialist

Department: Operations Technology Department

Reports To: Business Configuration Supervisor

Work Environment:  Remote

Position Summary

The Claims Systems Specialist will assist with investigating, troubleshooting, testing, and resolving system issues across multiple operational platforms, including TriZetto QicLink, VBA, WEX, ZRTE Repricing, and ZRXLD RX loading applications.

This role ensures efficient, timely resolutions, accurate documentation, and reliable system performance while serving as a subject matter expert and resource to operational teams.

Essential Duties and Responsibilities

• Investigate, troubleshoot, test, and resolve system issues across supported applications in a timely and consistent manner.
• Assist with document findings, resolutions, and outcomes within the issue management software.
• Assist with daily requests and inquiries.
• Serve as a resource for Plan Building, Provider Maintenance Specialists, Claims Analysts, Supervisors, and other stakeholders impacted by supported systems.
• Provide system access and maintain user logins and security controls.
• Assist with troubleshooting provider appeals, stop-loss, and aggregate claim processing questions.
• Collaborate across teams to test and implement new or upgraded technology, processes, standards, and procedures.
• Provide weekly status updates and escalate issues as needed.
• Assist with new and existing PBM, cost containment and other third-party integrations.
• Serve as backup support for other Operations Technology staff, including Customer Service and other daily operational tasks or projects as required.

Required Skills and Competencies:

Technical & Industry Knowledge

• Proficiency in the TriZetto QicLink application, VBA or other claims adjudication platform
• Medical terminology and coding knowledge (ICD, CPT, ADA)
• A plus if possess understanding of:
• COBRA
• ERISA
• Coordination of Benefits (COB)
• Claims processing workflows

Professional Skills

• Excellent research and problem-solving abilities
• Excellent written and verbal communication skills
• High attention to detail
• Ability to work independently and under stressful conditions
• Able to handle competing priorities

Leadership & Collaboration

• Team-oriented with a strong support mindset
• Demonstrated ability to train others
• Dependable and trustworthy

Experience and Qualifications

• 3+ years of experience working in a claims or related function at a TPA or health insurance carrier, preferably in claims processing experience or business configuration
• 2+ years of experience working with TriZetto QicLink or VBA
• Above average ability to use a computer
• Knowledge of group health insurance operations and ICD/CPT coding

Work Environment:

This position follows a remote work structure, allowing employees to work from home, based on specific tasks or personal work preferences.  There may be times when working in the office will be required.

Essential Functions:

This role may require extended sitting, regular computer and office equipment use, clear communication, and occasional lifting of up to 10–15 pounds. Reasonable accommodations for individuals with disabilities will be provided as needed.

Confidentiality: This position involves access to protected health information (PHI) and other sensitive data. Employees are expected to maintain strict confidentiality in accordance with HIPAA, company privacy policies, and all applicable federal and state regulations.